1
|
Kurashige T, Nakamura R, Murao T, Mine N, Sato M, Katsumata R, Kanaya Y, Dodo Y, Sugiura T, Ohshita T. Atypical skin conditions of the neck and back as a dermal manifestation of anti-HMGCR antibody-positive myopathy. BMC Immunol 2024; 25:30. [PMID: 38734636 PMCID: PMC11088225 DOI: 10.1186/s12865-024-00622-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/07/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Immune-mediated necrotizing myopathy (IMNM) is an idiopathic inflammatory myopathy (IIM). Though patients with IMNM were not considered to show skin rash, several reports have showed atypical skin conditions in patients with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibody-positive IMNM (HMGCR-IMNM). The incidence and phenotype of skin conditions in patients with HMGCR-IMNM are not fully known. RESULTS Among the 100 IIM patients diagnosed from April 2015 through August 2022, 34 (34%) presented some form of skin condition, with 27 having typical skin rashes; this included 13 patients with dermatomyositis (DM), 8 with anti-synthetase syndrome (ASS), and 6 with IMNM. Meanwhile, 8 of 19 patients with HMGCR-IMNM (42%) presented atypical skin lesions, but no patients with other IIMs did (p < 0.001). Skin eruption with ash-like scales was observed in four HMGCR-IMNM patients, and non-scaly red patches and lumps in the other four patients; accordingly, their skin manifestations were considered as other dermal diseases except for IIM. However, skin and muscle biopsies revealed the atypical skin conditions of patients with HMGCR-IMNM to have the same pathological background, formed by Bcl-2-positive lymphocyte infiltrations. CONCLUSIONS HMGCR-IMNM patients frequently have atypical skin conditions of the neck and back. Skin biopsy specimens from these lesions showed the same Bcl-2-positive lymphocytic infiltrations as muscle biopsy specimens regardless of the different gross dermal findings. Thus, such atypical skin conditions may be suggestive for HMGCR-IMNM.
Collapse
Affiliation(s)
- Takashi Kurashige
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan.
| | - Rie Nakamura
- Department of Dermatology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
- Department of Dermatology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Tomomi Murao
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
| | - Naoko Mine
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
- Department of Neurology, Chugoku Rosai Hospital, Kure, Japan
| | - Mayu Sato
- Department of Rheumatology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Riho Katsumata
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
| | - Yuhei Kanaya
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
| | - Yoriko Dodo
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
| | - Tomohito Sugiura
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
| | - Tomohiko Ohshita
- Department of Neurology, NHO Kure Medical Center, Chugoku Cancer Center, Kure, Japan
| |
Collapse
|
2
|
Koumas C, Michelassi F. Immune-Mediated Necrotizing Myopathies: Current Landscape. Curr Neurol Neurosci Rep 2024; 24:141-150. [PMID: 38589696 DOI: 10.1007/s11910-024-01337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Immune-mediated necrotizing myopathy (IMNM), characterized by acute or subacute onset, severe weakness, and elevated creatine kinase levels, poses diagnostic and therapeutic challenges. This article provides a succinct overview of IMNM, including clinical features, diagnostic strategies, and treatment approaches. RECENT FINDINGS Recent insights highlight the different clinical presentations and therapeutic options of IMNM stratified by autoantibody positivity and type. Additionally, recent findings call into question the reported link between statin use and IMNM. This review synthesizes current knowledge on IMNM, emphasizing its distinct clinical features and challenging management. The evolving understanding of IMNM underscores the need for a comprehensive diagnostic approach that utilizes a growing range of modalities. Early and aggressive immunomodulatory therapy remains pivotal. Ongoing research aims to refine diagnostic tools and therapeutic interventions for this challenging muscle disorder, underscoring the importance of advancing our understanding to enhance patient outcomes.
Collapse
Affiliation(s)
- Christoforos Koumas
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.
| | | |
Collapse
|
3
|
Tebo AE. Autoantibody evaluation in idiopathic inflammatory myopathies. Adv Clin Chem 2024; 120:45-67. [PMID: 38762242 DOI: 10.1016/bs.acc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024]
Abstract
Idiopathic inflammatory myopathies (IIM), generally referred to as myositis is a heterogeneous group of diseases characterized by muscle inflammation and/or skin involvement, diverse extramuscular manifestations with variable risk for malignancy and response to treatment. Contemporary clinico-serologic categorization identifies 5 main clinical groups which can be further stratified based on age, specific clinical manifestations and/or risk for cancer. The serological biomarkers for this classification are generally known as myositis-specific (MSAs) and myositis-associated antibodies. Based on the use of these antibodies, IIM patients are classified into anti-synthetase syndrome, dermatomyositis, immune-mediated necrotizing myopathy, inclusion body myositis, and overlap myositis. The current classification criteria for IIM requires clinical findings, laboratory measurements, and histological findings of the muscles. However, the use MSAs and myositis-associated autoantibodies as an adjunct for disease evaluation is thought to provide a cost-effective personalized approach that may not only guide diagnosis but aid in stratification and/or prognosis of patients. This review provides a comprehensive overview of contemporary autoantibodies that are specific or associated myositis. In addition, it highlights possible pathways for the detection and interpretation of these antibodies with limitations for routine clinical use.
Collapse
Affiliation(s)
- Anne E Tebo
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, United States.
| |
Collapse
|
4
|
Chaisrimaneepan N, Thongpiya J, Yingchoncharoen P, Saowapa S. An atorvastatin-induced positive anti-HMGCR immune-mediated necrotizing myopathy case. Clin Case Rep 2024; 12:e8563. [PMID: 38435506 PMCID: PMC10901786 DOI: 10.1002/ccr3.8563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
Statins can commonly cause myopathy. Most of the time, stopping the culprit drug should solve the problem. However, if the drug has been discontinued but muscle weakness continues to worsen, immune-mediated myopathy should be taken into consideration.
Collapse
Affiliation(s)
| | - Jerapas Thongpiya
- Department of Internal MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | | | - Sakditad Saowapa
- Department of Internal MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| |
Collapse
|
5
|
Julien S, Challier I, Malleter M, Jouen F, Drouot L, Boyer O. Immune-Mediated Necrotizing Myopathy (IMNM): A Story of Antibodies. Antibodies (Basel) 2024; 13:12. [PMID: 38390873 PMCID: PMC10885118 DOI: 10.3390/antib13010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/10/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a rare and severe disease that corresponds to a specific entity of idiopathic inflammatory myopathy. Patients with IMNM suffer from proximal muscle weakness, and present high levels of creatine kinase and necrotic myofibers. Anti-Signal Recognition Particle (SRP) and anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase autoantibodies (HMGCR) have recently been identified in two thirds of patients with IMNM and are used as a hallmark of the disease. In this review, we provide a detailed description of these antibodies and the tests used to detect them in the serum of patients. Based on in vitro studies and mouse models of IMNM, we discuss the role of autoantibodies in the pathogenesis of the disease. Finally, in the light of the latest knowledge, we conclude with a review of recent therapeutic approaches in IMNM.
Collapse
Affiliation(s)
- Sarah Julien
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
| | - Inès Challier
- Department of Pharmacy, CHU Rouen, F-76000 Rouen, France
| | - Marine Malleter
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
| | - Fabienne Jouen
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
- Department of Immunology and Biotherapy, CHU Rouen, F-76000 Rouen, France
| | - Laurent Drouot
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
| | - Olivier Boyer
- INSERM U1234, PAn'THER FOCIS Center of Excellence, Université de Rouen, F-76000 Rouen, France
- Department of Immunology and Biotherapy, CHU Rouen, F-76000 Rouen, France
| |
Collapse
|
6
|
Khoo T, Chinoy H. Anti-HMGCR immune-mediated necrotising myopathy: Addressing the remaining issues. Autoimmun Rev 2023; 22:103468. [PMID: 37884200 DOI: 10.1016/j.autrev.2023.103468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
The discovery of autoantibodies directed against the 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) enzyme has defined a sub-set of immune-mediated necrotising myopathy (IMNM) which is strongly associated with exposure to statin medications. Although understanding of anti-HMGCR IMNM has grown considerably with the reporting of multiple cohorts in North America, Europe, Asia and Oceania, there remain many unanswered questions. The true incidence of anti-HMGCR IMNM is not known and heterogeneity of phenotype and treatment response within this autoantibody sub-group is being increasingly recognised. Statin-naïve adults and juvenile patients with anti-HMGCR potentially share characteristics distinct from statin-exposed patients, alluding to unique pathogenesis. Conflicting data exists on whether malignancies are associated with anti-HMGCR and further clarification is required to determine the degree of cancer screening required. Treatment approaches to anti-HMGCR IMNM are heterogeneous but generally highlight the efficacy of intravenous immunoglobulin. Even with multimodal immunosuppression, patients with anti-HMGCR remain prone to relapse, with younger patients generally manifesting more refractory disease. In this Review, we aim to summarise the current literature on anti-HMGCR and discuss the remaining issues.
Collapse
Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, South Australia, Australia; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom.
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom
| |
Collapse
|
7
|
Yamamoto S, Yoshida A, Gono T, Kuwana M. The Role of Environmental Factors in the Development of Idiopathic Inflammatory Myopathies: a Narrative Review. Curr Rheumatol Rep 2023; 25:264-275. [PMID: 37971581 DOI: 10.1007/s11926-023-01120-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW This review aims to evaluate recent findings on the role of environmental factors in the development and clinical presentation of idiopathic inflammatory myopathies (IIMs). RECENT FINDINGS A targeted literature review was conducted to identify reports relevant to the association between environmental factors and IIMs published over the past three years. There has been an increasing number of publications dealing with the association of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or vaccination with the development of IIMs, highlighting the significant role of the antiviral immune response in the pathogenesis of the disease. Traditional environmental factors associated with the pathogenic process of IIM subclassifications included drugs such as statins and immune checkpoint inhibitors, ultraviolet radiation, smoking, air pollutants, and vitamin D deficiency. Correlations of seasonality and residence with the onset of certain IIM subtypes suggest a potential role of environmental triggers in the pathogenic process. An interplay between genetic predisposition and various environmental factors might contribute to the development of IIMs as well as the heterogeneous clinical and serological presentation of IIMs. The growing evidence on the role of environmental factors in the development of IIMs provides important clues to elucidate the pathophysiology of these disease entities. The mechanisms underlying the interactions between genetic predisposition and environmental factors should be investigated in the future.
Collapse
Affiliation(s)
- Shintaro Yamamoto
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Akira Yoshida
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan.
- Scleroderma/Myositis Center of Excellence, Nippon Medical School Hospital, Tokyo, Japan.
| |
Collapse
|
8
|
Julien S, van der Woning B, De Ceuninck L, Briand E, Jaworski T, Roussel G, Zoubaïri R, Allenbach Y, Benveniste O, Drouot L, Boyer O. Efgartigimod restores muscle function in a humanized mouse model of immune-mediated necrotizing myopathy. Rheumatology (Oxford) 2023; 62:4006-4011. [PMID: 37335864 DOI: 10.1093/rheumatology/kead298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/25/2023] [Accepted: 06/10/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE Immune-mediated necrotizing myopathies (IMNMs) are severe forms of myositis often associated with pathogenic anti-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) autoantibodies (aAbs). Efgartigimod is an engineered human IgG1 Fc fragment that antagonizes the neonatal Fc receptor (FcRn), thereby preventing recycling and promoting lysosomal degradation of IgG, including aAbs. We evaluated the therapeutic effects of IgG reduction by efgartigimod in a humanized murine model of IMNM. METHODS Disease was induced in C5-deficient (C5def) or Rag2-deficient (Rag2-/-) mice receiving co-injections of anti-HMGCR+ IgG from an IMNM patient and human complement. C5def mice were treated in a preventive setting with s.c. injections of efgartigimod and Rag2-/- mice in a curative setting after disease was induced by anti-HMGCR+ IgG injections. Anti-HMGCR aAbs levels were monitored in mouse serum and muscle tissue. Histological analysis was performed on muscle sections. Muscle force was assessed by grip test or measurement of gastrocnemius strength upon electrostimulation. RESULTS Administration of efgartigimod rapidly reduced total IgG levels, including the level of pathogenic anti-HMGCR aAbs, in both serum (P < 0.0001) and muscle (P < 0.001). In the preventive setting, efgartigimod prevented myofibre necrosis (P < 0.05), thus precluding loss of muscle strength (P < 0.05). In the therapeutic setting, efgartigimod prevented further necrosis and allowed muscle fibre regeneration (P < 0.05). Hence, muscle strength returned to normal (P < 0.01). CONCLUSION Efgartigimod reduces circulating IgG levels, including pathogenic anti-HMGCR+ IgG aAbs, in a humanized mouse model of IMNM, preventing further necrosis and allowing muscle fibre regeneration. These results support investigating the therapeutic efficacy of efgartigimod through a clinical trial in IMNM patients.
Collapse
Affiliation(s)
- Sarah Julien
- Univ Rouen Normandie, Inserm UMR1234, FOCIS Center of Excellence PAn'THER, Rouen, France
| | | | | | - Emma Briand
- Univ Rouen Normandie, Inserm UMR1234, FOCIS Center of Excellence PAn'THER, Rouen, France
| | - Thara Jaworski
- Univ Rouen Normandie, Inserm UMR1234, FOCIS Center of Excellence PAn'THER, Rouen, France
| | - Gaëlle Roussel
- Univ Rouen Normandie, Inserm UMR1234, FOCIS Center of Excellence PAn'THER, Rouen, France
| | - Rachid Zoubaïri
- Univ Rouen Normandie, Inserm UMR1234, FOCIS Center of Excellence PAn'THER, Rouen, France
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, AP-HP, Pitié-Salpêtrière University Hospital, Paris, France
| | - Olivier Benveniste
- Department of Internal Medicine and Clinical Immunology, AP-HP, Pitié-Salpêtrière University Hospital, Paris, France
| | - Laurent Drouot
- Univ Rouen Normandie, Inserm UMR1234, FOCIS Center of Excellence PAn'THER, Rouen, France
| | - Olivier Boyer
- Univ Rouen Normandie, Inserm UMR1234, FOCIS Center of Excellence PAn'THER, Rouen, France
| |
Collapse
|
9
|
Oeztuerk M, Henes A, Schroeter CB, Nelke C, Quint P, Theissen L, Meuth SG, Ruck T. Current Biomarker Strategies in Autoimmune Neuromuscular Diseases. Cells 2023; 12:2456. [PMID: 37887300 PMCID: PMC10605022 DOI: 10.3390/cells12202456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Inflammatory neuromuscular disorders encompass a diverse group of immune-mediated diseases with varying clinical manifestations and treatment responses. The identification of specific biomarkers has the potential to provide valuable insights into disease pathogenesis, aid in accurate diagnosis, predict disease course, and monitor treatment efficacy. However, the rarity and heterogeneity of these disorders pose significant challenges in the identification and implementation of reliable biomarkers. Here, we aim to provide a comprehensive review of biomarkers currently established in Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), myasthenia gravis (MG), and idiopathic inflammatory myopathy (IIM). It highlights the existing biomarkers in these disorders, including diagnostic, prognostic, predictive and monitoring biomarkers, while emphasizing the unmet need for additional specific biomarkers. The limitations and challenges associated with the current biomarkers are discussed, and the potential implications for disease management and personalized treatment strategies are explored. Collectively, biomarkers have the potential to improve the management of inflammatory neuromuscular disorders. However, novel strategies and further research are needed to establish clinically meaningful biomarkers.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany; (M.O.); (A.H.); (P.Q.)
| |
Collapse
|
10
|
Tan E, Knight J, Khonasti S, Nolan D, McGettigan B, Bundell C, Needham M, Brusch A. Clinical associations of patients with anti-3-hydroxy-3-methylglutaryl CoA reductase antibody-associated immune-mediated necrotising myopathy. Intern Med J 2023; 53:1846-1853. [PMID: 36625419 DOI: 10.1111/imj.16004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Anti-3-hydroxy-3-methylglutaryl CoA reductase (HMGCR) antibodies are associated with a subtype of immune-mediated necrotising myopathy (IMNM). AIMS To determine clinical associations of anti-HMGCR antibodies for anti-HMGCR-associated IMNM (HMGCR-IMNM) among a cohort of patients in Western Australia and to determine whether serial HMGCR antibody levels parallel disease activity. METHODS Adult patients with positive anti-HMGCR antibodies detected by enzyme-linked immunosorbent assay between January 2015 and November 2019 were included. Symptoms, examination findings, imaging findings and blood test results were reviewed retrospectively using patient records and laboratory database results. RESULTS Among 26 patients with positive anti-HMGCR antibodies, 23 were diagnosed with HMGCR-IMNM representing a positive predictive value (PPV) of 88%. Myopathy was frequently severe at diagnosis with limb weakness graded as Medical Research Council score 3 or below in 78% of patients, bulbar muscle weakness in 39% and an average creatine kinase (CK) at diagnosis of 7986 U/L. The majority (83%) required at least two therapies to maintain remission, 48% had at least one flare of disease and 57% did not achieve CK normalisation. Correlation between CK and anti-HMGCR antibody level at diagnosis was low (r = 0.04). Anti-HMGCR antibodies fell with treatment in 10 of 12 patients, but remained persistently positive in 83% of patients. CONCLUSIONS The PPV of anti-HMGCR antibodies for HMGCR-IMNM in this Western Australian cohort is 88%. Patients typically present with proximal limb weakness, dysphagia and markedly elevated CK, and, despite multiagent immunosuppression, a significant number of patients have evidence of persistent biochemical myositis. Anti-HMGCR antibodies did not correlate with CK levels at diagnosis.
Collapse
Affiliation(s)
- Elina Tan
- Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, Western Australia, Australia
| | - Jacinta Knight
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Steffi Khonasti
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David Nolan
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Benjamin McGettigan
- Department of Clinical Immunology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Chris Bundell
- Department of Immunology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
- School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Merrilee Needham
- Department of Neurology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
- Neuromuscular Clinic, Perron Institution for Neurological and Translational Science, QEII Medical Centre, Perth, Western Australia, Australia
| | - Anna Brusch
- Department of Immunology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
- Neuromuscular Clinic, Perron Institution for Neurological and Translational Science, QEII Medical Centre, Perth, Western Australia, Australia
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| |
Collapse
|
11
|
Oh EK, Lee SA, Lee HJ, Cha YJ, Kim S, Lee HS, Suh BC, Shin HY, Kim SW, Yoon BA, Oh SI, Kim YH, Cho JY, Cho JH, Kwon KH, Choi YC, Park HJ. Clinical and Radiological Features of Korean Patients With Anti-HMGCR Myopathy. J Clin Neurol 2023; 19:460-468. [PMID: 36929062 PMCID: PMC10471552 DOI: 10.3988/jcn.2022.0374] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND AND PURPOSE To understand the characteristics of Korean patients with anti-3-hydroxy-3-methylglutaryl-coenxyme A reductase (HMGCR) myopathy, we measured anti-HMGCR antibodies and analyzed the clinical, radiological, and pathological features of patients with anti-HMGCR myopathy. METHODS We measured titers of anti-HMGCR antibodies in the sera of 99 patients with inflammatory myopathy, 36 patients with genetic myopathy, and 63 healthy subjects using an enzyme-linked immunosorbent assay. We tested 16 myositis-specific autoantibodies (MSAs) in all patients with anti-HMGCR myopathy. RESULTS Positivity for the anti-HMGCR antibody was observed in 17 (4 males and 13 females) of 99 patients with inflammatory myopathy. The median age at symptom onset was 60 years. Ten (59%) of the patients with anti-HMGCR positivity had taken statins. The titer of anti-HMGCR antibodies was significantly higher in the statin-naïve group (median=230 U/mL, interquartile range=170-443 U/mL) than in the statin-exposed group (median=178 U/mL, interquartile range=105-210 U/mL, p=0.045). The most common symptom was proximal muscle weakness in 15 patients (88%), followed by myalgia in 9 (53%), neck weakness in 4 (24%), dysphagia in 3 (18%), and skin lesions in 2 (12%). The median titer of anti-HMGCR antibody was 202 U/mL. We found eight different MSAs in nine (53%) patients. The median disease duration from symptom onset to diagnosis was significantly shorter in the MSA-positive group than in the MSA-negative group (p=0.027). CONCLUSIONS Our study was the first to measure anti-HMGCR antibodies in inflammatory myopathy. It has provided new findings, including the suggestion of the coexistence of other MSAs in Korean patients.
Collapse
Affiliation(s)
- Eun Kyoung Oh
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Ah Lee
- Department of Neurology, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyun Joon Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Jin Cha
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sungjun Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung-Soo Lee
- Department of Neurology, Korea University Ansan Hospital, Ansan, Korea
| | - Bum Chun Suh
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Kim
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byeol-A Yoon
- Department of Neurology, Peripheral Neuropathy Research Center, College of Medicine, Dong-A University, Busan, Korea
| | - Seong-Il Oh
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yoo Hwan Kim
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Joong-Yang Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jeong Hee Cho
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ki-Han Kwon
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Young-Chul Choi
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Jun Park
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
12
|
Arcani R, Rey L, Mazziotto A, Bertin D, Kaplanski G, Jarrot PA, Lafforgue P, Venton G, Heim X, Villani P, Mège JL, Brodovitch A, Bardin N. Anti-Jo-1 autoantibodies: biomarkers of severity and evolution of the disease in antisynthetase syndrome. Arthritis Res Ther 2023; 25:125. [PMID: 37481643 PMCID: PMC10362709 DOI: 10.1186/s13075-023-03116-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/12/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Anti-Jo-1 autoantibodies represent essential markers in the diagnosis of antisynthetase syndrome (ASS). In this retrospective study, we aimed to investigate whether their concentrations and fluctuations could both respectively reflect the severity and evolution of ASS. METHODS Between 2015 and 2020, clinical and biological features of ASS patients with at least one positive measure of anti-Jo-1 autoantibody were collected. At each serum sampling, we assessed myositis activity by using the Myositis Intention to Treat Activities Index (MITAX) and compared anti-Jo-1 concentrations with ASS severity, anti-Jo-1 concentrations between patients with and without active disease, and changes in anti-Jo-1 concentrations with disease activity. RESULTS Forty-eight patients with ASS had at least one positive determination of anti-Jo-1 concentration. Among them, twenty-nine patients had at least two determinations of anti-Jo-1 autoantibody in their follow-up. We showed that these autoantibody concentrations were significantly correlated with MITAX (r = 0.4, p = 0.03) and creatine kinase concentration (r = 0.34, p = 0.002) and that they were significantly higher in patients with active disease than in those with inactive disease (91.7 IU/L vs 44.4 IU/L, p = 0.016). During follow-up, we found a significant correlation between fluctuations of anti-Jo-1 autoantibody concentrations and MITAX score (r = 0.7, p < 0.0001). CONCLUSION Our results suggest that anti-Jo-1 autoantibody concentration could be a predictive marker of the severity and evolution of ASS and show that their quantification could represent a precious tool for disease monitoring and for improving the therapeutic management of ASS patients.
Collapse
Affiliation(s)
- Robin Arcani
- Internal Medicine and Therapeutics Department, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), 264 Rue Saint-Pierre, 13005, Marseille, France.
- Center for Cardiovascular and Nutrition Research (C2VN), INRA, 1260, INSERM UMR_S 1263, Aix-Marseille University, Marseille, France.
| | - Louise Rey
- Biogénopôle, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Alice Mazziotto
- Internal Medicine and Therapeutics Department, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), 264 Rue Saint-Pierre, 13005, Marseille, France
| | - Daniel Bertin
- Biogénopôle, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Gilles Kaplanski
- Center for Cardiovascular and Nutrition Research (C2VN), INRA, 1260, INSERM UMR_S 1263, Aix-Marseille University, Marseille, France
- Department of Internal Medicine and Clinical Immunology, CHU La Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Pierre-André Jarrot
- Center for Cardiovascular and Nutrition Research (C2VN), INRA, 1260, INSERM UMR_S 1263, Aix-Marseille University, Marseille, France
- Department of Internal Medicine and Clinical Immunology, CHU La Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Pierre Lafforgue
- Department of Rheumatology, CHU Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Geoffroy Venton
- Hematology and Cellular Therapy Department, CHU La Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Xavier Heim
- Center for Cardiovascular and Nutrition Research (C2VN), INRA, 1260, INSERM UMR_S 1263, Aix-Marseille University, Marseille, France
- Biogénopôle, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Patrick Villani
- Internal Medicine and Therapeutics Department, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), 264 Rue Saint-Pierre, 13005, Marseille, France
| | - Jean-Louis Mège
- Biogénopôle, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Alexandre Brodovitch
- Biogénopôle, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Nathalie Bardin
- Center for Cardiovascular and Nutrition Research (C2VN), INRA, 1260, INSERM UMR_S 1263, Aix-Marseille University, Marseille, France
- Biogénopôle, CHU La Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| |
Collapse
|
13
|
Martirossian AN, Goldberg AC. Management of patients with statin intolerance. Best Pract Res Clin Endocrinol Metab 2023; 37:101714. [PMID: 36345572 PMCID: PMC10125408 DOI: 10.1016/j.beem.2022.101714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Atherosclerotic cardiovascular disease is a leading cause of morbidity and mortality, and statins have become a cornerstone in its treatment and prevention. Despite the well-documented benefits of statins, many patients stop taking them, with adverse muscle symptoms being a commonly cited reason. Although some statin-associated adverse muscle effects are real, some can be attributed to the nocebo effect, which is the patient's perception of harm. The purpose of this article is to review the literature on statin safety, particularly that related to muscle, to analyze adverse effects, and to propose various treatment strategies for the statin intolerant patient.
Collapse
Affiliation(s)
- Alexandra Nicole Martirossian
- Division of Endocrinology, Metabolism, and Lipid Research, John T., Milliken Department of Medicine, Washington University School of Medicine, Campus Box 8127, 660 South Euclid St. Louis, MO 63110, USA.
| | - Anne Carol Goldberg
- Division of Endocrinology, Metabolism, and Lipid Research, John T., Milliken Department of Medicine, Washington University School of Medicine, Campus Box 8127, 660 South Euclid St. Louis, MO 63110, USA.
| |
Collapse
|
14
|
Cheli M, Dinoto A, Sartori A, Bratina A, Manganotti P. Diagnostic and treatment challenges of 3-hydroxy-3-methylglutaryl-coenzyme A reductase myopathy: the possible role of muscle ultrasound. Neurol Sci 2023; 44:2203-2205. [PMID: 36849698 DOI: 10.1007/s10072-023-06700-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/17/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Marta Cheli
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447, 34149, Trieste, Italy.
| | - Alessandro Dinoto
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447, 34149, Trieste, Italy
| | - Arianna Sartori
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447, 34149, Trieste, Italy
| | - Alessio Bratina
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447, 34149, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447, 34149, Trieste, Italy
| |
Collapse
|
15
|
Abdalla MS, Zhang Q, Abdalla MO, Abdel-Jalil SS. Statin-Induced Immune-Mediated Necrotizing Myopathy Resulting in Proximal Muscle Weakness. J Med Cases 2023; 14:64-70. [PMID: 36896367 PMCID: PMC9990704 DOI: 10.14740/jmc4039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/28/2023] [Indexed: 02/27/2023] Open
Abstract
Statin-induced immune-mediated necrotizing myopathy (IMNM) is a subtype of IMNM linked to exposure to statins and is characterized by positive anti-hydroxymethylglutaryl (HMG) coenzyme A reductase (HMGCR) antibodies. Although rare, this entity has become increasingly recognized as a cause of proximal muscle weakness, especially with the widespread use of statin therapy. Unlike typical statin-associated muscle symptoms, IMNM myopathy often causes severe muscle injury, and muscle weakness persists or sometimes worsens following the withdrawal of statin therapy. Medical practitioners need to keep a high index of clinical suspicion for statin-induced IMNM in patients taking statins who present with muscle weakness. The disease can be debilitating, and treatment strategies are not well established despite the advances that have been made in the diagnosis. Here we present the clinical characteristics and disease course of two cases of statin-induced IMNM. Both patients presented with progressive proximal muscle weakness and myalgias while on long-term statin therapy without significant improvement in their symptoms following the withdrawal of statin therapy. IMNM was suspected, and both patients were found to have high titers of anti-HMG coenzyme A reductase antibodies and demonstrated microscopic features consistent with a diagnosis of IMNM on muscle biopsy. The patients experienced significant disability due to muscle weakness and required a protracted course of escalated immunosuppressive therapy. Although rare, IMNM should be suspected in patients taking statins who present with muscle weakness that fails to improve or worsens when statins were stopped. Early diagnosis and institution of immunosuppressive therapy are important to prevent the progression of the disease.
Collapse
Affiliation(s)
- Mohammed S Abdalla
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL, USA
| | - Qishuo Zhang
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL, USA
| | - Monzer O Abdalla
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL, USA
| | | |
Collapse
|
16
|
Mammen AL, Amato AA, Dimachkie MM, Chinoy H, Hussain Y, Lilleker JB, Pinal-Fernandez I, Allenbach Y, Boroojerdi B, Vanderkelen M, Delicha EM, Koendgen H, Farzaneh-Far R, Duda PW, Sayegh C, Benveniste O. Zilucoplan in immune-mediated necrotising myopathy: a phase 2, randomised, double-blind, placebo-controlled, multicentre trial. THE LANCET. RHEUMATOLOGY 2023; 5:e67-e76. [PMID: 36923454 PMCID: PMC10009502 DOI: 10.1016/s2665-9913(23)00003-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Immune-mediated necrotizing myopathy (IMNM) is an autoimmune myopathy characterised by proximal muscle weakness, high creatine kinase (CK) values, and autoantibodies recognizing 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) or the signal recognition particle (SRP). There are currently no approved therapies for IMNM and many patients experience active disease despite off-label treatment with intravenous immunoglobulin, glucocorticoids, and immunosuppressants. Detection of complement-activating anti-HMGCR and anti-SRP autoantibodies and the presence of complement deposition on the sarcolemma of non-necrotic myofibers led to the hypothesis that complement activation may be pathogenic in IMNM, therefore zilucoplan, a complement component 5 (C5) inhibitor, could be a potential therapy. Methods IMNM01, a phase 2, multicenter, randomised, double-blind, placebo-controlled study (NCT04025632) at 15 sites (four countries) evaluated efficacy, safety, and tolerability of zilucoplan in adult participants with anti-HMGCR or anti-SRP autoantibody-positive IMNM. Participants were randomised 1:1 to receive daily subcutaneous zilucoplan (0·3mg/kg) or placebo for eight weeks; with optional enrolment in the study open-label extension. Primary efficacy endpoint was percent change from baseline to Week 8 in CK levels. Secondary endpoints included safety. Findings Between 07 November 2019 and 07 January 2021, 27 participants (13 female and 14 male) received zilucoplan (n=12) or placebo (n=15) and completed the 8-week main study. At Week 8 there were no clinically relevant or statistically significant differences, despite target engagement based on mode of action, between treatment arms in mean percent change (standard deviation) of CK levels versus baseline (-9·86% [26·06] versus -20·72% [31·22] in zilucoplan [n=10] and placebo arms [n=14], p=0·46, respectively) and no clinically relevant improvement over time within the treatment arm. There were no unexpected adverse safety or tolerability findings. Treatment emergent adverse events (TEAEs) and serious TEAEs were reported in n=9 (75·0%) vs n=13 (86·7%) and n=0 (0%) and n=3 (20·0%) participants, respectively. The most frequent TEAEs were headache (n=4 in both groups [33·3% and 26·7%, respectively]) and nausea (n=3 in both groups [25·0% and 20·0%, respectively]). Interpretation C5 inhibition does not appear to be an effective treatment modality for IMNM. Rather than driving myofiber necrosis, complement activation may be secondary to muscle injury. Funding Study funded by Ra Pharmaceuticals (now part of UCB Pharma).
Collapse
Affiliation(s)
- Andrew L Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anthony A Amato
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas USA
| | - Hector Chinoy
- National Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, The University of Manchester, Manchester, UK; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Yessar Hussain
- Austin Neuromuscular Center, The University of Texas Dell Medical School, Austin, Texas, USA
| | - James B Lilleker
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester, Manchester, UK; Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Iago Pinal-Fernandez
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, Sorbonne Université, Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France; Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, Centre de Recherche en Myologie, UMRS974, Paris, France
| | | | | | | | | | | | | | | | - Olivier Benveniste
- Department of Internal Medicine and Clinical Immunology, Sorbonne Université, Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France; Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, Centre de Recherche en Myologie, UMRS974, Paris, France
| |
Collapse
|
17
|
Sener S, Batu ED, Sari S, Kasap Cuceoglu M, Yildiz AE, Talim B, Aydingoz U, Ozen S, Haliloglu G. A Child with Refractory and Relapsing Anti-3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Myopathy: Case-Based Review. J Neuromuscul Dis 2023; 10:279-291. [PMID: 36617789 DOI: 10.3233/jnd-221557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND/OBJECTIVE Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy is rare in children. Here, we present a boy with relapsing refractory anti-HMGCR myopathy along with a systematic literature review. CASE REPORT 17-year-old boy with five years of muscle weakness, rash, high creatinine kinase (CK) levels, and muscle biopsy compatible with inflammatory myopathy was diagnosed with juvenile dermatomyositis. He was treated with corticosteroids, intravenous immunoglobulin (IVIG), and methotrexate. His muscle weakness improved with this treatment although never completely resolved. CK levels decreased from ∼15000 U/L to ∼3000 U/L. At the age of 15, muscle weakness relapsed after an upper respiratory tract infection; pulse corticosteroid treatment was administered. The re-evaluated muscle biopsy showed a necrotizing pattern and the HMGCR antibody was positive confirming anti-HMGCR myopathy when he was 16. The diagnostic delay was 50 months. Disease activity was monitored by Medical Research Council score, MRI and functional tests. Despite corticosteroids, methotrexate, IVIG, cyclosporine A, and rituximab therapies, muscle weakness improved only slightly during the first three months and remained stable afterwards.Results of the Literature Search:We identified 16 articles describing 50 children (76% female) with anti-HMGCR myopathy by reviewing the English literature up to March 1st, 2022. Proximal muscle weakness was the most common clinical symptom (70.8%). Corticosteroids (84.8%), IVIG (58.7%), and methotrexate (56.5%) were preferred in most cases. Complete remission was achieved in nine patients (28.1%). CONCLUSION Diagnosis and management of children with anti-HMGCR myopathy are challenging. Complete remission is achieved in only one third of these patients. Imaging biomarkers may aid treatment.
Collapse
Affiliation(s)
- Seher Sener
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Deniz Batu
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seher Sari
- Department of Pediatrics, Division of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Muserref Kasap Cuceoglu
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Adalet Elcin Yildiz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Beril Talim
- Division of Pediatric Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ustun Aydingoz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatrics, Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Goknur Haliloglu
- Department of Pediatrics, Division of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
18
|
Wang CH, Liang WC. Pediatric immune-mediated necrotizing myopathy. Front Neurol 2023; 14:1123380. [PMID: 37021281 PMCID: PMC10067916 DOI: 10.3389/fneur.2023.1123380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a type of inflammatory myopathy. Most patients with IMNM produce anti-3-hydroxy-3-methylglutaryl coenzyme A reductase or anti-signal-recognition particle autoantibodies. IMNM is much rarer in children than in adults. We conducted this mini review focusing on pediatric IMNM to present current evidence regarding its epidemiology, clinical characteristics, diagnosis, and treatment. Our findings indicate that pediatric IMNM often causes severe muscle weakness and is refractory to corticosteroids alone. Furthermore, delayed diagnosis is common because of the clinicopathological similarity between IMNM and inherited myopathy. Raising awareness regarding pediatric IMNM may facilitate early diagnosis and effective treatment.
Collapse
Affiliation(s)
- Chen-Hua Wang
- Department of Pediatrics, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Wen-Chen Liang,
| |
Collapse
|
19
|
Ma X, Bu BT. Anti-SRP immune-mediated necrotizing myopathy: A critical review of current concepts. Front Immunol 2022; 13:1019972. [PMID: 36311711 PMCID: PMC9612835 DOI: 10.3389/fimmu.2022.1019972] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/12/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose of review This review aims to describe clinical and histological features, treatment, and prognosis in patients with anti-signal recognition particle (SRP) autoantibodies positive immune-mediated necrotizing myopathy (SRP-IMNM) based on previous findings. Previous findings Anti-SRP autoantibodies are specific in IMNM. Humoral autoimmune and inflammatory responses are the main autoimmune characteristics of SRP-IMNM. SRP-IMNM is clinically characterized by acute or subacute, moderately severe, symmetrical proximal weakness. Younger patients with SRP-IMNM tend to have more severe clinical symptoms. Patients with SRP-IMNM may be vulnerable to cardiac involvement, which ought to be regularly monitored and cardiac magnetic resonance imaging is the recommended detection method. The pathological features of SRP-IMNM are patchy or diffuse myonecrosis and myoregeneration accompanied by a paucity of inflammatory infiltrates. Endoplasmic reticulum stress-induced autophagy pathway and necroptosis are activated in skeletal muscle of SRP-IMNM. Treatment of refractory SRP-IMNM encounters resistance and warrants further investigation. Summary Anti-SRP autoantibodies define a unique population of IMNM patients. The immune and non-immune pathophysiological mechanisms are involved in SRP-IMNM.
Collapse
Affiliation(s)
- Xue Ma
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Bi-Tao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Bi-Tao Bu,
| |
Collapse
|
20
|
Prevention of Anti-HMGCR Immune-Mediated Necrotising Myopathy by C5 Complement Inhibition in a Humanised Mouse Model. Biomedicines 2022; 10:biomedicines10082036. [PMID: 36009583 PMCID: PMC9405589 DOI: 10.3390/biomedicines10082036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: immune-mediated necrotising myopathy (IMNM) is associated with pathogenic anti-signal recognition particle (SRP) or 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibodies, at least partly through activation of the classical pathway of the complement. We evaluated zilucoplan, an investigational drug, and a macrocyclic peptide inhibitor of complement component 5 (C5), in humanized mouse models of IMNM. Methods: purified immunoglobulin G (IgG) from an anti-HMGCR+ IMNM patient was co-injected intraperitoneally with human complement in C57BL/6, C5-deficient B10 (C5def) and Rag2 deficient (Rag2−/−) mice. Zilucoplan was administered subcutaneously in a preventive or interventional paradigm, either injected daily throughout the duration of the experiment in C57BL/6 and C5def mice or 8 days after disease induction in Rag2−/− mice. Results: prophylactic administration of zilucoplan prevented muscle strength loss in C5def mice (anti-HMGCR+ vs. anti-HMGCR+ + zilucoplan: p = 0.0289; control vs. anti-HMGCR+ + zilucoplan: p = 0.4634) and wild-type C57BL/6 (anti-HMGCR+ vs. anti-HMGCR+ + zilucoplan: p = 0.0002; control vs. anti-HMGCR+ + zilucoplan: p = 0.0939) with corresponding reduction in C5b-9 deposits on myofibres and number of regenerated myofibres. Interventional treatment of zilucoplan after disease induction reduced the complement deposits and number of regenerated myofibres in muscles of Rag2−/− mice, although to a lesser extent. In this latter setting, C5 inhibition did not significantly ameliorate muscle strength. Conclusion: Early administration of zilucoplan prevents the onset of myopathy at the clinical and histological level in a humanized mouse model of IMNM.
Collapse
|
21
|
Galindo-Feria AS, Wang G, Lundberg IE. Autoantibodies: Pathogenic or epiphenomenon. Best Pract Res Clin Rheumatol 2022; 36:101767. [PMID: 35810122 DOI: 10.1016/j.berh.2022.101767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Idiopathic inflammatory myopathies (IIM) are heterogeneous autoimmune diseases. There are distinct subgroups, including antisynthetase syndrome, dermatomyositis, polymyositis, immune-mediated necrotizing myopathy, and sporadic inclusion body myositis. In patients with IIM, autoantibodies are present in up to 80% of the patients. These autoantibodies are often characterized as myositis-specific autoantibodies (MSA) or myositis-associated autoantibodies (MAA). The recognition of the importance of autoantibodies, especially MSA, is increasing in recent years. In this chapter, we provide an overview of the MSAs, including some new autoantibodies of interest as they target mainly muscle-specific autoantigen, in clinical classification, the measurement of the disease activity, and a possible role in the pathogenesis in the patients with IIM.
Collapse
Affiliation(s)
- Angeles S Galindo-Feria
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden; Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden.
| | - Guochun Wang
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Ingrid E Lundberg
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden; Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden.
| |
Collapse
|
22
|
Barrons R. Statin-Associated Autoimmune Myopathy: Review of the Literature. J Pharm Pract 2022; 36:383-393. [PMID: 35707933 DOI: 10.1177/08971900211040291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Statin-associated autoimmune myopathy (SAAM) is a rare adverse event characterized by progressive muscle symptoms despite discontinuation, requiring immunosuppressive therapy for remission. The objective of this review was to characterize SAAM, for timely detection, while examining the literature for effective treatment considerations. METHODS PubMed search was conducted from 2010 to 2020 was for relevant case series and studies of at least 8 patients displaying muscle discomfort or weakness, anti-HMGCR antibodies, exposure to statins, and biopsies consistent with SAAM. RESULTS Three case series and 3 case cohort studies identified 199 patients with SAAM. Exhibiting a mean age of 63.74 years, patients were more likely Caucasian (81%) and female (1.2X), and required a mean duration of 4.75 years before symptomatic. The presentation involved proximal muscle weakness (94%), myalgias (37%) and dysphagia (23%), accompanied by a mean creatinine kinase of 6383 IU/L. Most patients (57%) required 2 or more immunosuppressive (IMS) agents to achieve 62% remission. After 2 years of treatment, 15% of patients without remission reported symptomatic improvement, while another 12% were refractory to treatment. CONCLUSION Delayed onset of SAAM greater than 4 years from statin initiation may create a low index of suspicion. However, progression of symptoms beyond 2 months from statin discontinuation and positive anti-HMGCR antibodies requires immunosuppressive agents. Data and expert opinion support use of at least two IMS medications upon diagnosis for a minimum of 2 years. Therapy success depends on timely recognition and initiation of IMS combinations to achieve earlier remission and symptomatic improvement.
Collapse
Affiliation(s)
- Robert Barrons
- School of Pharmacy, 15543Wingate University, Wingate, NC, USA
| |
Collapse
|
23
|
A Case Report of Statin-Induced Immune-Mediated Necrotizing Myopathy Treatment Challenges. Case Rep Rheumatol 2022; 2022:4647227. [PMID: 35685894 PMCID: PMC9173901 DOI: 10.1155/2022/4647227] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/16/2022] [Indexed: 12/02/2022] Open
Abstract
Statin-induced necrotizing autoimmune myopathy is an immune-mediated necrotizing myopathy related to the use of statins. It is a very rare disease, which usually presents with proximal muscle weakness and frank elevation in creatine kinase levels. Stopping statin and the use of immunosuppressive therapy are considered the mainstay therapy. Use of steroids in patients with inflammatory myopathy can be complicated by steroid-induced myopathy. Herein, we present a case of a 55-year-old patient with statin-induced necrotizing autoimmune myopathy based on the presence of proximal muscle weakness, magnetic resonance findings, suggestive muscle biopsy features, and positive anti-HMGCR autoantibodies. The patient was treated with triple immunosuppressive therapy with a particularly good response to intravenous immunoglobulin. This report highlights the importance of timely diagnosis and early use of combined immunosuppressive therapy to improve patients' outcome affected by this rare disease.
Collapse
|
24
|
Szczesny P, Barsotti S, Nennesmo I, Danielsson O, Dastmalchi M. Screening for Anti-HMGCR Antibodies in a Large Single Myositis Center Reveals Infrequent Exposure to Statins and Diversiform Presentation of the Disease. Front Immunol 2022; 13:866701. [PMID: 35603214 PMCID: PMC9114810 DOI: 10.3389/fimmu.2022.866701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background The objective of this study is to assess the frequency of autoantibodies against 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR) in a single center myositis cohort and to analyze associations with statin exposure, clinical features, and outcome of disease course. Methods A total of 312 patients with idiopathic inflammatory myopathies (IIMs) followed at the rheumatology clinic, Karolinska University Hospital, were identified in the Euromyositis registry between 1988 and 2014 and were classified according to the 2017 European Alliance of Associations for Rheumatology/American College of Rheumatology (EULAR/ACR) criteria. Available serum samples were analyzed for anti-HMGCR autoantibodies by ELISA. Positive sera were confirmed by immunoprecipitation. Clinical data were extracted from Euromyositis registry and medical records. Muscle samples were examined by two pathologists blinded to the subjects' autoantibody status. Results Of 312 patients, 13 (4.3%) were positive for anti-HMGCR. Two of the 13 (15%) anti-HMGCR-positive patients had histories of statin use versus 12 (4.2%) in the anti-HMGCR-negative group. In the anti-HMGCR-positive group, five (38%) had a clinical phenotype compatible with dermatomyositis. Muscle biopsies of patients with HMGCR autoantibodies showed findings consistent with immune-mediated necrotizing myopathy in all cases except for one. Five (38%) patients required treatment with intravenous immunoglobulin compared to seven (2.3%) without this antibody. At the last visit, seven patients had chronic, active disease course, and five of 13 patients were in remission, including three without treatment. Conclusions Patients with IIM related to anti-HMGCR autoantibodies may present with a wide range of symptoms, more than previously anticipated. When a broad approach to screening for these antibodies is applied, only a minority of patients was found to have previous statin exposure. The results of this study justify the addition of anti-HMGCR autoantibodies to routine diagnostic procedures in patients with myositis.
Collapse
Affiliation(s)
- Piotr Szczesny
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Simone Barsotti
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Rheumatology Outpatient Clinic, Livorno Hospital, Livorno, Italy
| | - Inger Nennesmo
- Department of Laboratory Medicine Karolinska Institutet, Stockholm, Sweden
| | - Olof Danielsson
- Division of Neurology, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linkoping University, Linkoping, Sweden
| | - Maryam Dastmalchi
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Division of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
25
|
Pathophysiological Mechanisms and Treatment of Dermatomyositis and Immune Mediated Necrotizing Myopathies: A Focused Review. Int J Mol Sci 2022; 23:ijms23084301. [PMID: 35457124 PMCID: PMC9030619 DOI: 10.3390/ijms23084301] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 12/15/2022] Open
Abstract
Idiopathic inflammatory myopathies (IIM), collectively known as myositis, are a composite group of rare autoimmune diseases affecting mostly skeletal muscle, although other organs or tissues may also be involved. The main clinical feature of myositis is subacute, progressive, symmetrical muscle weakness in the proximal arms and legs, whereas subtypes of myositis may also present with extramuscular features, such as skin involvement, arthritis or interstitial lung disease (ILD). Established subgroups of IIM include dermatomyositis (DM), immune-mediated necrotizing myopathy (IMNM), anti-synthetase syndrome (ASyS), overlap myositis (OM) and inclusion body myositis (IBM). Although these subgroups have overlapping clinical features, the widespread variation in the clinical manifestations of IIM suggests different pathophysiological mechanisms. Various components of the immune system are known to be important immunopathogenic pathways in IIM, although the exact pathophysiological mechanisms causing the muscle damage remain unknown. Current treatment, which consists of glucocorticoids and other immunosuppressive or immunomodulating agents, often fails to achieve a sustained beneficial response and is associated with various adverse effects. New therapeutic targets have been identified that may improve outcomes in patients with IIM. A better understanding of the overlapping and diverging pathophysiological mechanisms of the major subgroups of myositis is needed to optimize treatment. The aim of this review is to report on recent advancements regarding DM and IMNM.
Collapse
|
26
|
Liu L, Tessier S, Ido F, Longo S, Nanda S. Anti-3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase (Anti-HMG CoA) Myopathy With Cardiac Involvement: Presentation, Diagnosis, and Management. Cureus 2022; 14:e23125. [PMID: 35425681 PMCID: PMC9004697 DOI: 10.7759/cureus.23125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is categorized into three groups: anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) IMNM, anti-signal recognition particle (SRP) IMNM, and seronegative IMNM. Cardiac involvement has been reported in a significant segment of patients with IMNM of the anti-SRP type. Emerging evidence now suggests that cardiac involvement is also implicated in the anti-HMGCR subgroup. In this report, we present a case of anti-HMGCR IMNM with cardiac involvement demonstrated by elevated troponin levels, a low ejection fraction of 40%, and regional wall motion abnormalities in the inferior, inferolateral, anteroseptal, inferoseptal, and anterolateral myocardial walls, as visualized on echocardiography. These findings markedly improved after treatment with intravenous immunoglobulin (IVIG) and prednisone. This case and other recent reports highlight the need for a cardiac workup in patients diagnosed with anti-HMGCR IMNM.
Collapse
|
27
|
Kruse RL, Albayda J, Vozniak SO, Lawrence CE, Goel R, Lokhandwala PM, Ness PM, Tobian AAR, Bloch EM, Crowe EP. Therapeutic plasma exchange for the treatment of refractory necrotizing autoimmune myopathy. J Clin Apher 2022; 37:253-262. [PMID: 35119135 PMCID: PMC9303676 DOI: 10.1002/jca.21968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/04/2022] [Accepted: 01/14/2022] [Indexed: 11/30/2022]
Abstract
Introduction Necrotizing autoimmune myopathy (NAM) is strongly associated with pathognomonic autoantibodies targeting 3‐hydroxy‐3‐methylglutaryl‐coenzyme A reductase (HMGCR) or signal recognition particle (SRP), whose levels in turn are correlated with serum creatine kinase (CK) and necrosis. Thus, NAM may be amenable to therapeutic plasma exchange (TPE) to remove pathogenic antibodies and improve patient symptoms. Methods A retrospective case series and literature review of patients presenting with NAM and undergoing treatment with TPE was performed. Clinical data including patient demographics, symptoms, physical exam findings, muscle biopsy, lower extremity imaging, prior therapy, and duration from diagnosis to TPE initiation were collected retrospectively for adult patients with NAM treated with TPE after failing to respond to immunomodulatory therapy. Laboratory data including change in CK levels and myositis‐specific antibody titers from baseline were measured in some patients. Results Six patients (median age at diagnosis 52.5 years, interquartile range [IQR] 35.8‐64.5 years, four male/two female) underwent a median of 7.5 (IQR: 5‐10) TPE procedures with 5% albumin as replacement. All patients exhibited a statistically significant reduction in CK level from pre‐TPE baseline (range: 43.0%‐58.7% reduction). Responses in this cohort were best in patients with antibodies targeting HMGCR and SRP, which are most strongly associated with NAM. These results compare favorably to a literature review of NAM patients (n = 19) treated with TPE, who also exhibited positive clinical and laboratory responses across varying treatment lengths. Conclusion TPE can play a role in the management of NAM, particularly in patients with HMGCR or SRP antibodies who are refractory to pharmacologic immunosuppression.
Collapse
Affiliation(s)
- Robert L Kruse
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jemima Albayda
- Division of Rheumatology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Sonja O Vozniak
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Courtney E Lawrence
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Division of Hematology Oncology, Department of Internal Medicine, Simmons Cancer Institute at Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Parvez M Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,American Red Cross, Baltimore, Maryland, USA
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Elizabeth P Crowe
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| |
Collapse
|
28
|
Shelly S, Mielke MM, Paul P, Milone M, Tracy JA, Mills JR, Klein CJ, Ernste FC, Mandrekar J, Liewluck T. Incidence and Prevalence of Immune-mediated Necrotizing Myopathy in Adults in Olmsted County, Minnesota. Muscle Nerve 2022; 65:541-546. [PMID: 35064938 PMCID: PMC9035036 DOI: 10.1002/mus.27504] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/12/2022] [Accepted: 01/15/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION/AIMS Immune-mediated necrotizing myopathy (IMNM) is considered a rare subtype of the immune-mediated myopathies, but its incidence and prevalence are unknown. This study aimed to determine the incidence and prevalence of IMNM in the adults in Olmsted County, Minnesota. METHODS We identified adult patients with IMNM defined by the 2016 European Neuromuscular Centre diagnostic criteria among Olmsted County, Minnesota, residents over a 20-year period RESULTS: Seven patients fulfilled the inclusion criteria. Six patients were tested for IMNM antibodies: 4 were anti 3-Hydroxy-3-Methylglutaryl-CoA Reductase (HMGCR)-positive, 1 was anti-signal recognition particle (SRP)-positive and 1 was seronegative. The incidence of IMNM during 2010-2019 was 8.3 per million person-years. The prevalence of IMNM in 2010 was 1.85 per 100,000 people ≥50 years. Median age at symptom onset was 64 years (range: 52-86) and median time from symptom onset to diagnosis was 3 months (range <1-156). Statin use among anti-HMGCR IMNM patients, but not the entire IMNM cohort, was higher than in controls (P=0.024). Two IMNM patients developed cancers. The incidence of malignancy in IMNM was not higher than that of the general population. Treatment outcome was favorable in all patients except for 1 with delayed treatment and one with insufficient therapy. Among 3 deceased patients, 1 died from cancer while 2 died from IMNM-related cardiorespiratory complications. DISCUSSION IMNM is a rare disease. Its prevalence is one tenth that of inclusion body myositis in Olmsted County, Minnesota. IMNM patients in our cohort were not at higher risk for developing cancer.
Collapse
Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN.,Department of Neurology, Chaim Sheba Medical Center, Tel HaShomer, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Michelle M Mielke
- Department of Neurology, Mayo Clinic, Rochester, MN.,Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Pritikanta Paul
- Department of Neurology, Mayo Clinic, Rochester, MN.,Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL
| | | | | | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Floranne C Ernste
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jay Mandrekar
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
29
|
Hou Y, Shao K, Yan Y, Dai T, Li W, Zhao Y, Li D, Lu JQ, Norman GL, Yan C. Anti-HMGCR myopathy overlaps with dermatomyositis-like rash: a distinct subtype of idiopathic inflammatory myopathy. J Neurol 2022; 269:280-293. [PMID: 34021410 DOI: 10.1007/s00415-021-10621-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/13/2021] [Accepted: 05/18/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To characterize the clinical and pathological features of anti-HMGCR myopathy. METHODS The presence of anti-HMGCR antibody in the serum of 227 patients with idiopathic inflammatory myopathy (IIM) and 100 healthy control individuals was assessed by ELISA. All ELISA positive samples were retested by indirect immunofluorescence assay (IIFA) on HEK293 cells. The clinical findings, muscle pathological features, and treatment outcomes of patients with anti-HMGCR myopathy, along with comparisons between anti-HMGCR myopathy with and without dermatomyositis (DM)-like skin rashes, and among MSA-based subgroups were analyzed. RESULTS We established an optimized ELISA cutoff for anti-HMGCR antibody positivity as ≥ 5.28 U. The overall concordance between ELISA and IIFA was 96.83%. Twenty-one out of 227 IIM patients were anti-HMGCR-positive by both assays. Of these 21 patients, 9 had DM-like skin rashes, and 16 showed remarkable muscle inflammation; 5 patients were juvenile-onset, and 2 received statin treatment. The muscle biopsies from these patients demonstrated variable muscle necrosis and T cell infiltration. Most anti-HMGCR-positive patients achieved favorable outcomes following prednisone and additional immunotherapies. The anti-HMGCR myopathy patients with DM-like rashes, compared to those without DM-like rashes, were younger and had a shorter disease duration. CONCLUSIONS Optimization of cutoff of anti-HMGCR antibody assays with confirmation by alternative assays can result in higher sensitivity and specificity. DM-like skin rashes and lymphocytic infiltrates were not rare in patients with anti-HMGCR myopathy. These findings suggest that while anti-HMGCR myopathy may overlap with DM-like rash, it is pathologically different from classic DM, and should be considered a distinct subgroup of IIM.
Collapse
Affiliation(s)
- Ying Hou
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, China
| | - Kai Shao
- Department of Central Laboratory and Mitochondrial Medicine Laboratory, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Yaping Yan
- Key Laboratory of the Ministry of Education for Medicinal Resources and Natural Pharmaceutical Chemistry, National Engineering Laboratory for Resource Development of Endangered Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xian, China
| | - Tingjun Dai
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, China
| | - Wei Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, China
| | - Yuying Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, China
| | - Duoling Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, China
| | - Jian-Qiang Lu
- Neuropathology Section, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Chuanzhu Yan
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, Shandong, China. .,Department of Central Laboratory and Mitochondrial Medicine Laboratory, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China. .,Brain Science Research Institute, Shandong University, Jinan, China.
| |
Collapse
|
30
|
Lundberg IE, Fujimoto M, Vencovsky J, Aggarwal R, Holmqvist M, Christopher-Stine L, Mammen AL, Miller FW. Idiopathic inflammatory myopathies. Nat Rev Dis Primers 2021; 7:87. [PMID: 34857780 PMCID: PMC10425161 DOI: 10.1038/s41572-021-00325-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Idiopathic inflammatory myopathies (IIM), also known as myositis, are a heterogeneous group of autoimmune disorders with varying clinical manifestations, treatment responses and prognoses. Muscle weakness is usually the classical clinical manifestation but other organs can be affected, including the skin, joints, lungs, heart and gastrointestinal tract, and they can even result in the predominant manifestations, supporting that these are systemic inflammatory disorders. Different myositis-specific autoantibodies have been identified and, on the basis of clinical, histopathological and serological features, IIMs can be classified into several subgroups — dermatomyositis (including amyopathic dermatomyositis), antisynthetase syndrome, immune-mediated necrotizing myopathy, inclusion body myositis, polymyositis and overlap myositis. The prognoses, treatment responses and organ manifestations vary among these groups, implicating different pathophysiological mechanisms in each subtype. A deeper understanding of the molecular pathways underlying the pathogenesis and identifying the autoantigens of the immune reactions in these subgroups is crucial to improve outcomes. New, more homogeneous subgroups defined by autoantibodies may help define disease mechanisms, and will also be important in future clinical trials to develop targeted therapies and in identifying biomarkers to guide treatment decisions for the individual patient.
Collapse
Affiliation(s)
- Ingrid E. Lundberg
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, and Karolinska University Hospital. Stockholm, Sweden
| | - Manabu Fujimoto
- Department of Dermatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jiri Vencovsky
- Institute of Rheumatology, Prague, Czech Republic
- Deptartment of Rheumatology, 1st Medical Faculty, Charles University, Prague, Czech Republic
| | - Rohit Aggarwal
- UPMC Myositis Center, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie Holmqvist
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, and Karolinska University Hospital. Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Lisa Christopher-Stine
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew L. Mammen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Departments of Neurology and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frederick W. Miller
- Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA
| |
Collapse
|
31
|
Abstract
Idiopathic inflammatory myopathies (IIM), also known as myositis, are a heterogeneous group of autoimmune disorders with varying clinical manifestations, treatment responses and prognoses. Muscle weakness is usually the classical clinical manifestation but other organs can be affected, including the skin, joints, lungs, heart and gastrointestinal tract, and they can even result in the predominant manifestations, supporting that IIM are systemic inflammatory disorders. Different myositis-specific auto-antibodies have been identified and, on the basis of clinical, histopathological and serological features, IIM can be classified into several subgroups - dermatomyositis (including amyopathic dermatomyositis), antisynthetase syndrome, immune-mediated necrotizing myopathy, inclusion body myositis, polymyositis and overlap myositis. The prognoses, treatment responses and organ manifestations vary among these groups, implicating different pathophysiological mechanisms in each subtype. A deeper understanding of the molecular pathways underlying the pathogenesis and identifying the auto-antigens of the immune reactions in these subgroups is crucial to improving outcomes. New, more homogeneous subgroups defined by auto-antibodies may help define disease mechanisms and will also be important in future clinical trials for the development of targeted therapies and in identifying biomarkers to guide treatment decisions for the individual patient.
Collapse
|
32
|
Merlonghi G, Antonini G, Garibaldi M. Immune-mediated necrotizing myopathy (IMNM): A myopathological challenge. Autoimmun Rev 2021; 21:102993. [PMID: 34798316 DOI: 10.1016/j.autrev.2021.102993] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/14/2021] [Indexed: 02/07/2023]
Abstract
This review is focused on the myopathological spectrum of immune mediated necrotizing myopathies (IMNMs) and its differentiation with other, potentially mimicking, inflammatory and non-inflammatory myopathies. IMNMs are a subgroup of idiopathic inflammatory myopathies (IIMs) characterized by severe clinical presentation with rapidly progressive muscular weakness and creatine kinase elevation, often requiring early aggressive immunotherapy, associated to the presence of muscle specific autoantibodies (MSA) against signal recognition particle (SRP) or 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR). Muscle biopsy usually shows unspecific features consisting in prominent necrosis and regeneration of muscle fibres with mild or absent inflammatory infiltrates, inconstant and faint expression of major histocompatibility complex (MHC) class I and variable deposition of C5b-9 on sarcolemma. Several conditions could present similar histopathological findings leading to possible misdiagnosis of IMNM with other IIMs or non-inflammatory myopathies (nIMs) and viceversa. This review analyses the muscle biopsy data in IMNMs through a systematic revision of the literature from the last five decades. Several histopathological variables have been considered in both SRP- and HMGCR-IMNM, and compared to other IIMs - as dermatomyositis (DM) and anti-synthethase syndrome (ASS) - or other nIMs -as toxic myopathies (TM), critical illness myopathy (CIM) and muscular dystrophy (MD) - to elucidate similarities and differences among these potentially mimicking conditions. The major histopathological findings of IMNMs were: very frequent necrosis and regeneration of muscle fibres (93%), mild inflammatory component mainly constituted by scattered isolated (65%) CD68-prevalent (68%) cells, without CD8 invading/surrounding non-necrotic fibres, variable expression of MHC-I in non-necrotic fibres (56%) and constant expression of sarcoplasmic p62, confirming those that are widely considered the major histological characteristics of IMNMs. Conversely, only 42% of biopsies showed a sarcolemmal deposition of C5b-9 component. Few differences between SRP and HMGCR IMNMs consisted in more severe necrosis and regeneration in SRP than in HMGCR (p = 0.01); more frequent inflammatory infiltrates (p = 0.007) with perivascular localization (p = 0.01) and clustered expression of MHC-I (p = 0.007) in HMGCR; very low expression of sarcolemmal C5b-9 in SRP (18%) compared to HMGCR (56%) (p = 0.0001). Milder necrosis and regeneration, detection of perifascicular pathology, presence of lymphocytic inflammatory infiltrates and myofibre expression of MxA help to distinguish DM or ASS from IMNM. nIMs can present signs of inflammation at muscle biopsy. Low fibre size variability with overexpression of both MHC-I and II, associated with C5b-9 deposition, could could be observed in CIM, while increased connective tissue should lead to consider MD, or TM in absence of C5b-9 deposition. Nevertheless, these features are not constantly detected and muscle biopsy could not be diriment. For this reason, muscle biopsy should always be critically considered in light of the clinical context before concluding for a definite diagnosis of IMNM, only based on histopathological findings. More rigorous collection and analysis of muscle biopsy is warranted to obtain a higher quality and more homogeneous histopathological data in inflammatory myopathies.
Collapse
Affiliation(s)
- Gioia Merlonghi
- Neuromuscular and Rare Disease Centre, Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Giovanni Antonini
- Neuromuscular and Rare Disease Centre, Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Matteo Garibaldi
- Neuromuscular and Rare Disease Centre, Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Sant'Andrea Hospital, Rome, Italy.
| |
Collapse
|
33
|
Tsamis KI, Boutsoras C, Kaltsonoudis E, Pelechas E, Nikas IP, Simos YV, Voulgari PV, Sarmas I. Clinical features and diagnostic tools in idiopathic inflammatory myopathies. Crit Rev Clin Lab Sci 2021; 59:219-240. [PMID: 34767470 DOI: 10.1080/10408363.2021.2000584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Idiopathic inflammatory myopathies (IIMs) are rare autoimmune disorders affecting primarily muscles, but other organs can be involved. This review describes the clinical features, diagnosis and treatment for IIMs, namely polymyositis (PM), dermatomyositis (DM), sporadic inclusion body myositis (sIBM), immune-mediated necrotizing myopathy (IMNM), and myositis associated with antisynthetase syndrome (ASS). The diagnostic approach has been updated recently based on the discovery of circulating autoantibodies, which has enhanced the management of patients. Currently, validated classification criteria for IIMs allow clinical studies with well-defined sets of patients but diagnostic criteria to guide the care of individual patients in routine clinical practice are still missing. This review analyzes the clinical manifestations and laboratory findings of IIMs, discusses the efficiency of modern and standard methods employed in their workup, and delineates optimal practice for clinical care. Α multidisciplinary diagnostic approach that combines clinical, neurologic and rheumatologic examination, evaluation of electrophysiologic and morphologic muscle characteristics, and assessment of autoantibody immunoassays has been determined to be the preferred approach for effective management of patients with suspected IIMs.
Collapse
Affiliation(s)
- Konstantinos I Tsamis
- Department of Neurology, University Hospital of Ioannina, Ioannina, Greece.,School of Medicine, European University Cyprus, Nicosia, Cyprus.,Department of Physiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | | | | | | | - Ilias P Nikas
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Yannis V Simos
- Department of Physiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | | | - Ioannis Sarmas
- Department of Neurology, University Hospital of Ioannina, Ioannina, Greece
| |
Collapse
|
34
|
Vinci P, Panizon E, Tosoni LM, Cerrato C, Pellicori F, Mearelli F, Biasinutto C, Fiotti N, Di Girolamo FG, Biolo G. Statin-Associated Myopathy: Emphasis on Mechanisms and Targeted Therapy. Int J Mol Sci 2021; 22:11687. [PMID: 34769118 PMCID: PMC8583847 DOI: 10.3390/ijms222111687] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/10/2021] [Accepted: 10/13/2021] [Indexed: 12/25/2022] Open
Abstract
Hyperlipidemia is a major risk factor for cardiovascular morbidity and mortality. Statins are the first-choice therapy for dyslipidemias and are considered the cornerstone of atherosclerotic cardiovascular disease (ASCVD) in both primary and secondary prevention. Despite the statin-therapy-mediated positive effects on cardiovascular events, patient compliance is often poor. Statin-associated muscle symptoms (SAMS) are the most common side effect associated with treatment discontinuation. SAMS, which range from mild-to-moderate muscle pain, weakness, or fatigue to potentially life-threatening rhabdomyolysis, are reported by 10% to 25% of patients receiving statin therapy. There are many risk factors associated with patient features and hypolipidemic agents that seem to increase the risk of developing SAMS. Due to the lack of a "gold standard", the diagnostic test for SAMS is based on a clinical criteria score, which is independent of creatine kinase (CK) elevation. Mechanisms that underlie the pathogenesis of SAMS remain almost unclear, though a high number of risk factors may increase the probability of myotoxicity induced by statin therapy. Some of these, related to pharmacokinetic properties of statins and to concomitant therapies or patient characteristics, may affect statin bioavailability and increase vulnerability to high-dose statins.
Collapse
Affiliation(s)
- Pierandrea Vinci
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Emiliano Panizon
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Letizia Maria Tosoni
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Carla Cerrato
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Federica Pellicori
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Filippo Mearelli
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Chiara Biasinutto
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy;
| | - Nicola Fiotti
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Filippo Giorgio Di Girolamo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy;
| | - Gianni Biolo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| |
Collapse
|
35
|
Abstract
Purpose of Review The idiopathic inflammatory myopathies are a heterogeneous group of autoimmune disorders characterized by skeletal muscle inflammation leading to chronic muscle weakness. Immune-mediated necrotizing myopathy (IMNM) is a distinct subgroup of inflammatory myopathy typically characterized by myofiber necrosis with minimal inflammatory infiltrates on muscle biopsy, highly elevated creatine kinase levels, and infrequent extra-muscular involvement. This review provides an overview of currently recommended treatment strategies for IMNM, including discussion of disease activity monitoring and recommended first-line immunomodulatory agents depending on clinical phenotype and autoantibody status. Recent Findings IMNM can be divided into three subtypes based on autoantibody positivity: anti-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) IMNM, anti-signal recognition particle (SRP) IMNM, and antibody negative IMNM. Autoantibody status in IMNM has considerable correlation with clinical phenotype, prognosis, and recommended choice of immunosuppressive agent. Patients with anti-HMGCR IMNM tend to respond well to intravenous immunoglobulin (IVIG), and IVIG monotherapy may be sufficient treatment for certain patients. In anti-SRP IMNM, early rituximab is commonly favored. More generally, prompt initiation of aggressive immunosuppression is often indicated, as both anti-SRP and anti-HMGCR IMNM can potentially cause debilitating weakness, and muscle atrophy and irreversible fatty replacement happen early in the disease course. Patients with IMNM frequently require combination therapy to achieve disease control, and have a high rate of relapse when tapering immunosuppression. Young age of onset is a poor prognostic factor. Summary IMNM can be severely disabling and often requires aggressive immunosuppression. For any given patient, the treatment strategy should be informed by the severity of their presenting features and autoantibody status. While our ability to treat IMNM has certainly improved, there remains a need for more prospective trials to inform optimal treatment strategies.
Collapse
|
36
|
Ahmad A, Karam I, Baker DL. A Rapidly Debilitating Myopathy: A Rare Case of Statin-Induced Necrotizing Myositis. Cureus 2021; 13:e16304. [PMID: 34405065 PMCID: PMC8352795 DOI: 10.7759/cureus.16304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 12/03/2022] Open
Abstract
Statins are well tolerated in general but can be associated with myopathies. Statin-induced myopathies can range widely from mild myalgias to necrotizing autoimmune myopathies. We present a case of an 81-year-old man on statins for five years with no complications, who developed progressive muscle weakness, rhabdomyolysis, and dysphagia. His laboratory workup revealed elevated inflammatory markers with creatine kinase (CK) levels above 2000 U/L. The myositis panel was negative, and the anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody was positive. His muscle biopsy showed randomly scattered necrotic fibers with minimal perivascular inflammation confirming statin-induced necrotizing autoimmune myopathy (SINAM). Statins were discontinued immediately after initial suspicion. The patient was started on intravenous immunoglobulin followed by hydrocortisone and mycophenolate mofetil. The patient continued to have muscle weakness and progressive dysphagia to the point that he could not handle his secretions. His disease course was complicated by recurrent aspiration pneumonia. Percutaneous endoscopic gastrostomy tube placement was considered, but his family decided on hospice care given his overall comorbidities. Physicians should note that SINAM can occur after a few months to several years of statin use. This disease can be rapidly debilitating and progress even after discontinuation of statins, and treatment requires immunosuppressants, including steroids and steroid-sparing agents.
Collapse
Affiliation(s)
- Anam Ahmad
- Internal Medicine, St. Luke's Hospital, Chesterfield, USA
| | - Imad Karam
- Internal Medicine, St. Luke's Hospital, Chesterfield, USA
| | | |
Collapse
|
37
|
Lorenzo-Villalba N, Andrès E, Meyer A. Chronic Onset Form of Anti-HMG-CoA Reductase Myopathy. Eur J Case Rep Intern Med 2021; 8:002672. [PMID: 34268274 PMCID: PMC8276931 DOI: 10.12890/2021_002672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 11/30/2022] Open
Abstract
We report a case of anti-HMGCR myopathy mimicking limb-girdle muscular dystrophy in a 27-year-old male patient with no history of statin intake and presenting with a chronic onset form over 3 years. Treatment with prednisone and methotrexate was initiated with an insufficient response, so intravenous immunoglobulin was added. One year after initial treatment was started, as levels of creatine kinase (CK) were >1000 U/l, treatment with rituximab was added. Despite a 3-year delay before treatment, muscle strength improved even though CK levels remain elevated.
Collapse
Affiliation(s)
- Noel Lorenzo-Villalba
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasboug, France
| | - Emmanuel Andrès
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasboug, France
| | - Alain Meyer
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, France
| |
Collapse
|
38
|
Wong VT, So H, Lam TT, Yip RM. Myositis-specific autoantibodies and their clinical associations in idiopathic inflammatory myopathies. Acta Neurol Scand 2021; 143:131-139. [PMID: 32762037 DOI: 10.1111/ane.13331] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/14/2020] [Accepted: 07/30/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Myositis-specific autoantibodies (MSAs) have been found to be present predominantly in patients with idiopathic inflammatory myopathies (IIMs). This study aimed to investigate the prevalence of MSAs and their associated complications in a cohort of patients with IIMs. METHODS This was a multicentered prospective study. Consecutive adult Chinese patients with IIMs in the regional hospitals in Hong Kong were followed up from July 2016 to January 2018. Clinical characteristics, treatment history, and disease complications were documented. A commercially available immunoblot assay was used to detect the MSAs. RESULTS Out of the 201 patients studied, at least one MSA was found in 63.2% of patients. The most common among the identified MSAs were the anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab) and the anti-transcriptional intermediary factor 1-gamma antibody (anti-TIF1-γ Ab) (both 13.9%), followed by anti-Jo-1 antibody (12.4%). Anti-MDA5 was present exclusively in dermatomyositis (DM) and was strongly associated with digital ulcers, amyopathy, and rapidly progressive interstitial lung disease (RP-ILD). Anti-TIF1γ was strongly associated with refractory rash and malignancy. Independent risk factors of RP-ILD included anti-MDA5 (OR 14.5), clinically amyopathic DM (OR 13.9), and history of pulmonary tuberculosis (OR 12.2). Cox regression analysis showed that anti-TIF1γ (HR 3.55), DM (HR 3.82), and family history of cancer (HR 3.40) were independent predictors of malignancy. CONCLUSIONS MSA testing enables dividing of patients with IIMs into phenotypically homogeneous subgroups and prediction of potentially life-threatening complications.
Collapse
Affiliation(s)
| | - Ho So
- Department of Medicine and Therapeutics The Chinese University of Hong Kong New Territories Hong Kong
| | - Tommy Tsz‐On Lam
- Department of Medicine and Therapeutics The Chinese University of Hong Kong New Territories Hong Kong
| | | |
Collapse
|
39
|
Zuppa A, De Michelis C, Meo G, Prada V, Gemelli C, Infantino M, Manfredi M, Pesce G, Tagliafico AS, Benedetti L, Fiorillo C, Schenone A, Quartuccio L, Grandis M. Maintenance treatment with subcutaneous immunoglobulins in the long-term management of anti-HMCGR myopathy. Neuromuscul Disord 2021; 31:134-138. [PMID: 33461845 DOI: 10.1016/j.nmd.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/24/2022]
Abstract
We describe the clinical response to long-term subcutaneous immunoglobulins (SCIg) in anti-3‑hydroxy-3-methyl-glutaryl-coenzyme-A-reductase (anti-HMCGR) myopathy previously treated with intravenous immunoglobulins (IVIg). We collected data from patients affected by anti-HMGCR myopathy, switched from IVIg to SCIg therapy, after achieving clinical stabilization. The Medical Research Council sum score, creatine kinase (CK) levels, and anti-HMGCR antibodies were used to assess the response. We identified three patients with anti-HMGCR myopathy treated with SCIg with a favourable clinical course, allowing the maintenance of clinical stability, the reduction or suspension of steroids therapy and in two of them a complete CK normalization. Finally, anti-HMGCR antibodies tested in all patients after 12 months from SCIg starting, showed a global decrease. SCIg represent an useful alternative to long-term IVIg as already well known in several autoimmune neuromuscular disorders and inflammatory myopathies with advantages of lower side effects and home self-administration.
Collapse
Affiliation(s)
- Angela Zuppa
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy
| | - Chiara De Michelis
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy
| | - Giuseppe Meo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy
| | - Valeria Prada
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Gemelli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy
| | - Maria Infantino
- Immunology and Allergy Laboratory, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, Firenze, Italy
| | - Mariangela Manfredi
- Immunology and Allergy Laboratory, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, Firenze, Italy
| | - Giampaola Pesce
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Autoimmunity Laboratory Department of Internal Medicine (DiMI), University of Genova, Genova, Italy
| | - Alberto S Tagliafico
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Health Sciences (DISSAL), University of Genova, Genova, Italy
| | - Luana Benedetti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Fiorillo
- Department of Neuroscience, Paediatric Neurology and Neuromuscular Disorders, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Angelo Schenone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Luca Quartuccio
- Clinic of Rheumatology, Department of Medical Area (DAME), University - Hospital " Santa Maria della Misericordia", Udine, Italy
| | - Marina Grandis
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Largo P. Daneo3, 16132 Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| |
Collapse
|
40
|
Kurashige T, Murao T, Mine N, Sugiura T, Inazuka Y, Kuraoka K, Takahashi T, Maruyama H, Torii T. Anti-HMGCR Antibody-Positive Myopathy Shows Bcl-2-Positive Inflammation and Lymphocytic Accumulations. J Neuropathol Exp Neurol 2020; 79:448-457. [PMID: 32100014 PMCID: PMC7092361 DOI: 10.1093/jnen/nlaa006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/11/2019] [Accepted: 01/17/2020] [Indexed: 11/12/2022] Open
Abstract
Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) and antisignal recognition particle (SRP) antibodies are frequently associated with immune-mediated necrotizing myopathy (IMNM). However, the difference in clinical manifestations between anti-HMGCR and anti-SRP antibodies is unclear. HMGCR is an essential enzyme for cholesterol biosynthesis and is inhibited by statins that regulate apoptosis of Bcl-2-positive and beta chemokine receptor 4 (CCR4)-positive lymphoma cells. In this study, we aimed to clarify Bcl-2 and CCR4 expressions of lymphocytes in anti-HMGCR antibody-positive IMNM and explore the difference between anti-HMGCR antibody-positive myopathy and other inflammatory myopathies. We retrospectively examined Bcl-2- and CCR4-positive lymphocyte infiltrations in muscle and skin biopsy specimens from 19 anti-HMGCR antibody-positive patients and 75 other idiopathic inflammatory myopathies (IIMs) patients. A higher incidence of Bcl-2- and CCR4-positive lymphocytes was detected in the muscle and skin of anti-HMGCR antibody-positive IMNM patients (p < 0.001). In 5 patients with anti-HMGCR antibodies, Bcl-2-positive lymphocytes formed lymphocytic accumulations, which were not observed in other IIMs. Low-density lipoprotein cholesterol levels were not increased except for patients with Bcl-2-positive lymphocytic accumulations (p = 0.010). Bcl-2 and CCR4 lymphocyte infiltrations could be a pathological characteristic of anti-HMGCR antibody-positive IMNM.
Collapse
Affiliation(s)
- Takashi Kurashige
- Department of Neurology.,Department of Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Higashihiroshima, Hiroshima, Japan
| | | | | | | | | | - Kazuya Kuraoka
- Department of Diagnostic Pathology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Hiroshima, Japan
| | - Tetsuya Takahashi
- Department of Neurology.,Department of Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Higashihiroshima, Hiroshima, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Higashihiroshima, Hiroshima, Japan
| | | |
Collapse
|
41
|
Barrons R, Woods JA, Humphries R. Statin Associated Autoimmune Myonecrosis: Case Report With Delayed Onset and Treatment Challenges. J Pharm Pract 2020; 35:129-134. [PMID: 32924771 DOI: 10.1177/0897190020958223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE A case of delayed statin associated autoimmune myopathy (SAAM) is presented along with review of clinical findings and treatment strategies. SUMMARY A 54 year old male presented with proximal extremity weakness, difficulty ambulating, and dysphagia. Symptoms began when restarting atorvastatin 40 mg daily for a recent NSTEMI, following 10 years of statin use, interrupted after diagnosis of NASH. Relevant labs included CK of 13,618 IU/L, ALT/ AST of 568/407 IU/L, while additional liver, renal, and toxicology tests were normal. Following treatment response to prednisone 40 mg daily for 3 days, outpatient testing for anti-HMGCR antibodies was ordered.Twelve days from discharge, the patient was readmitted for myalgia and dysphagia, CK = 6042 IU/L, ALT/AST = 360/112 IU/L, and positive anti-HMGCR antibodies. Newly diagnosed with SAAM, symptoms improved with methylprednisolone and intravenous immunoglobulin (IVIG), continuing outpatient as daily prednisone and monthly IVIG. Four days later, the patient relapsed with worsened weakness and dysphagia, CK = 5812 IU/L, and ALT/AST = 647/337 IU/L. After response to methylprednisolone and rituximab, the patient was discharged on a corticosteroid taper, biweekly rituximab, and monthly IVIG. Two weeks later, a final admission involved a syncopal episode and fall, with a CK = 1461 IU/L. Treatment included IVIG, rituximab, and corticosteroid taper, which lead to remission for greater than 6 months. CONCLUSION Statin associated autoimmune myopathy occurred when restarting atorvastatin, following 10 years of statin use. Clinical findings and positive anti-HMGCR antibodies confirmed the diagnosis. Recurrent relapses required triple combination therapy including addition of rituximab to achieve remission.
Collapse
|
42
|
Mizus MC, Tiniakou E. Lipid-lowering Therapies in Myositis. Curr Rheumatol Rep 2020; 22:70. [PMID: 32845379 PMCID: PMC7986053 DOI: 10.1007/s11926-020-00942-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW The use of lipid-lowering therapies in patients with idiopathic inflammatory myopathies (IIM) is complicated and there are no guidelines for diagnosing, monitoring, or treating atherosclerotic cardiovascular disease (ASCVD) in this group of patients. RECENT FINDINGS The use of lipid-lowering therapies, especially statins, is recommended in patients with increased risk for ASCVD, which includes patients with inflammatory diseases, based on recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines for ASCVD management. There is accumulating evidence that patients with IIM are at increased risk for ASCVD, similar to other inflammatory diseases. Lipid-lowering therapies have side effects that may be pronounced or confounding in myositis patients, potentially limiting their use. Statins are specifically contraindicated in patients with anti 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibodies. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to be safe and potentially beneficial in patients with IIM. Here, we propose a framework for (1) ASCVD risk assessment and treatment based on ACC/AHA ASCVD primary prevention guidelines; (2) myositis disease monitoring while undergoing lipid-lowering therapy; and (3) management of statin intolerance, including, indications for the use of PCSK9 inhibitors.
Collapse
Affiliation(s)
- Marisa C Mizus
- Department of Medicine, Division of Rheumatology, Mason Lord, Center Tower, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Eleni Tiniakou
- Department of Medicine, Division of Rheumatology, Mason Lord, Center Tower, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| |
Collapse
|
43
|
|
44
|
Liang WC, Wang CH, Chen WZ, Kuo YT, Lin HF, Suzuki S, Nishino I, Jong YJ. Treatment experience of Taiwanese patients with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase myopathy. Kaohsiung J Med Sci 2020; 36:649-655. [PMID: 32666706 DOI: 10.1002/kjm2.12240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/06/2020] [Indexed: 11/08/2022] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) has emerged as a new subgroup of idiopathic inflammatory myopathy in the past decade, associated with the presence of two autoantibodies against signal recognition particle and 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR). We aim to analyze the clinical, pathological, and imaging phenotypes of the patients with anti-HMGCR myopathy in our cohort. Five patients with anti-HMGCR myopathy have been enrolled who were all female; three were pediatric and two were adult patients. The muscle pathology of patients met the diagnostic criteria of IMNM. On muscle magnetic resonance imaging, adductors were earliest affected while lower legs were relatively preserved with highest degree of involvement in medial head of gastrocnemius. In upper extremities, biceps brachii was the most severely involved, followed by triceps. All patients were refractory to steroid mono-therapy. For pediatric patients, all three patients eventually became responsive to steroid with either intravenous immunoglobulin or rituximab despite variable motor function recovered at present due to different intervention timing. For adult patients, one with statin exposure responded well to steroid and azathioprine use and the motor function returned to the baseline. The other adult patient finally got stabilized and slowly improved with steroid and methotrexate 13 years after the start of therapy. The creatine kinase (CK) levels of all patients were decreased along with clinical severity. In conclusion, muscle imaging might be of help for the diagnosis. Treatment with immuno-suppressants could be considered together with steroid from the beginning.
Collapse
Affiliation(s)
- Wen-Chen Liang
- Department of Pediatrics, Translational Research Center of Neuromuscular Diseases, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chen-Hua Wang
- Department of Pediatrics, Translational Research Center of Neuromuscular Diseases, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wan-Zi Chen
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yun-Ting Kuo
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Hsiu-Fen Lin
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | | | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuh-Jyh Jong
- Department of Pediatrics, Translational Research Center of Neuromuscular Diseases, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| |
Collapse
|
45
|
Yamamura Y, Matsumoto Y, Tadokoro K, Ohta Y, Sato K, Yamashita T, Yamamura M, Sada KE, Abe K, Wada J. Recovery from hypoxemia and Hypercapnia following noninvasive pressure support ventilation in a patient with statin-associated necrotizing myopathy: a case report. BMC Pulm Med 2020; 20:156. [PMID: 32493279 PMCID: PMC7268346 DOI: 10.1186/s12890-020-01195-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background Statin-associated necrotizing myopathy (SANM) is a rare autoimmune disorder caused by administration of statins. SANM is characterized by weakness due to necrosis and regeneration of myofibers. Here we report the first case of SANM with acute respiratory failure treated with noninvasive pressure support ventilation in addition to immunosuppressants. Case presentation A 59-year-old woman who had been treated with 2.5 mg/day of rosuvastatin calcium for 5 years stopped taking the drug 4 months before admission to our hospital due to elevation of creatine kinase (CK). Withdrawal of rosuvastatin for 1 month did not decrease the level of CK, and she was admitted to our hospital due to the development of muscle weakness of her neck and bilateral upper extremities. Anti-3-hydroxy-3-methylglutaryl coenzyme A reductase antibodies were positive. Magnetic resonance imaging showed myositis, and muscle biopsy from the right biceps brachii muscle showed muscle fiber necrosis and regeneration without inflammatory cell infiltration, suggesting SANM. After the diagnosis, she received methylprednisolone pulse therapy (mPSL, 1 g/day × 3 days, twice) and subsequent oral prednisolone therapy (PSL, 30 mg/day for 1 month, 25 mg/day for 1 month and 22.5 mg/day for 1 month), leading to improvement of her muscle weakness. One month after the PSL tapering to 20 mg/day, her muscle weakness deteriorated with oxygen desaturation (SpO2: 93% at room air) due to hypoventilation caused by weakness of respiratory muscles. BIPAP was used for the management of acute respiratory failure in combination with IVIG (20 g/day × 5 days) followed by mPSL pulse therapy (1 g/day × 3 days), oral PSL (30 mg/day × 3 weeks, then tapered to 25 mg/day) and tacrolimus (3 mg/day). Twenty-seven days after the start of BIPAP, she was weaned from BIPAP with improvement of muscle weakness, hypoxemia and hypercapnia. After she achieved remission with improvement of muscle weakness and reduction of serum CK level to a normal level, the dose of oral prednisolone was gradually tapered to 12.5 mg/day without relapse for 3 months. Conclusions Our report provides new insights into the role of immunosuppressants and biphasic positive airway pressure for induction of remission in patients with SANM.
Collapse
Affiliation(s)
- Yuriko Yamamura
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| | - Yoshinori Matsumoto
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan.
| | - Koh Tadokoro
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| | - Yasuyuki Ohta
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| | - Kota Sato
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| | - Toru Yamashita
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| | - Masahiro Yamamura
- Center for Rheumatology, Okayama Saiseikai General Hospital, Okayama, 700-8511, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| | - Koji Abe
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
| |
Collapse
|
46
|
Velardo D, Faravelli I, Cinnante C, Moggio M, Comi GP. Pediatric anti-HMGCR necrotizing myopathy: diagnostic challenges and literature review. Neurol Sci 2020; 41:3009-3013. [PMID: 32488450 DOI: 10.1007/s10072-020-04491-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/16/2020] [Accepted: 05/28/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Daniele Velardo
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
| | - Irene Faravelli
- Neurology Unit, Neuroscience Section, Department of Pathophysiology and Transplantation, Dino Ferrari Centre, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Claudia Cinnante
- Neuroradiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Maurizio Moggio
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Giacomo Pietro Comi
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Neurology Unit, Neuroscience Section, Department of Pathophysiology and Transplantation, Dino Ferrari Centre, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
| |
Collapse
|
47
|
Abstract
Although generally well tolerated, statin users frequently report muscle-related side effects, ranging from self-limiting myalgias to rhabdomyolysis or the rare clinical entity of statin-associated immune-mediated necrotizing myopathy (IMNM). Statin-associated IMNM is based on the development of autoantibodies against 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), the rate-limiting enzyme in cholesterol synthesis and the pharmacologic target of statins, and leads to a necrotizing myopathy requiring immunosuppressive therapy. This review attempts to recapitulate the diverse aspects of anti-HMGCR IMNM, including clinical presentation, diagnostic modalities, genetic risk associations, therapeutic options and potential pathogenetic pathways.
Collapse
Affiliation(s)
- Eleni Tiniakou
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Rheumatology, Baltimore, MD, USA
| |
Collapse
|
48
|
Abstract
Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of inflammatory myopathies whose common feature is immune-mediated muscle injury. There are distinct subgroups including dermatomyositis (DM), polymyositis (PM), inclusion body myositis, and immune-mediated necrotizing myopathy. Antisynthetase syndrome is also emerging as a distinct subgroup with its unique muscle histopathological characteristic of perifascicular necrosis. While the newly updated EULAR/ACR Classification Criteria for IIM have brought advancements in diagnosis and the exclusion of mimickers, the use of only one autoantibody in the derivation of the schema limits its use. Similarly, while the advent of multiple novel therapeutics in the treatment of myositis has been exciting, it has also highlighted the scarcity of validated outcome measures. The purpose of our review is to highlight the updated classification criteria of myositis, newly reported clinical phenotypes associated with myositis autoantibodies, the measurement of outcomes, and emerging treatments in the field.
Collapse
Affiliation(s)
- Sara Baig
- Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Suite 1B.1, Baltimore, MD 21224 USA
| | - Julie J Paik
- Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL Building, Center Tower Suite 4500, Baltimore, MD 21224 USA.
| |
Collapse
|
49
|
Qasim Agha O, Kaur S, Vijayavel N. Statin-induced necrotising autoimmune myopathy and autoimmune hepatitis presenting with dysphagia. BMJ Case Rep 2020; 13:13/2/e232391. [PMID: 32029513 DOI: 10.1136/bcr-2019-232391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Statin-induced necrotising autoimmune myopathy (SINAM) is a rare disease characterised by proximal muscle weakness and elevated creatine kinase levels that is usually in the thousands. Anti-3-hydroxy-3-methyl glutaryl co-enzyme A reductase (HMGCR) antibodies are associated with SINAM. Autoimmune hepatitis (AIH) is an inflammatory disease of the liver that is usually of unknown aetiology but can also be associated with concurrent extrahepatic autoimmune disorders. We are reporting a case of biopsy proven AIH associated with SINAM in a patient presenting with oropharyngeal dysphagia. The patient had elevated anti-HMGCR antibodies and anti-smooth muscle antibodies. SINAM and AIH were confirmed by muscle biopsy and liver biopsy, respectively. The patient had complete resolution of his symptoms and complete normalisation of his liver function tests after 6 months of the treatment.
Collapse
Affiliation(s)
- Osama Qasim Agha
- Department of Internal Medicine, St. Jospeh's Hospital and Medical Center, Phoenix, Arizona, USA .,Department of Internal Medicine, Creighton University School of Medicine, Phoenix, Arizona, USA
| | - Sukhdeep Kaur
- Department of Internal Medicine, St. Jospeh's Hospital and Medical Center, Phoenix, Arizona, USA.,Department of Internal Medicine, Creighton University School of Medicine, Phoenix, Arizona, USA
| | | |
Collapse
|
50
|
Meyer A, Troyanov Y, Drouin J, Oligny-Longpré G, Landon-Cardinal O, Hoa S, Hervier B, Bourré-Tessier J, Mansour AM, Hussein S, Morin V, Rich E, Goulet JR, Chartrand S, Hudson M, Nehme J, Makhzoum JP, Zarka F, Villeneuve E, Raynauld JP, Landry M, O'Ferrall EK, Ferreira J, Ellezam B, Karamchandani J, Larue S, Massie R, Isabelle C, Deschênes I, Leclair V, Couture H, Targoff IN, Fritzler MJ, Senécal JL. Statin-induced anti-HMGCR myopathy: successful therapeutic strategies for corticosteroid-free remission in 55 patients. Arthritis Res Ther 2020; 22:5. [PMID: 31915059 PMCID: PMC6950801 DOI: 10.1186/s13075-019-2093-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/23/2019] [Indexed: 01/21/2023] Open
Abstract
Objective To describe successful therapeutic strategies in statin-induced anti-HMGCR myopathy. Methods Retrospective data from a cohort of 55 patients with statin-induced anti-HMGCR myopathy, sequentially stratified by the presence of proximal weakness, early remission, and corticosteroid and IVIG use at treatment induction, were analyzed for optimal successful induction and maintenance of remission strategies. Results A total of 14 patients achieved remission with a corticosteroid-free induction strategy (25%). In 41 patients treated with corticosteroids, only 4 patients (10%) failed an initial triple steroid/IVIG/steroid-sparing immunosuppressant (SSI) induction strategy. Delay in treatment initiation was independently associated with lower odds of successful maintenance with immunosuppressant monotherapy (OR 0.92, 95% CI 0.85 to 0.97, P = 0.015). While 22 patients (40%) presented with normal strength, only 9 had normal strength at initiation of treatment. Conclusion While corticosteroid-free treatment of anti-HMGCR myopathy is now a safe option in selected cases, initial triple steroid/IVIG/SSI was very efficacious in induction. Delays in treatment initiation and, as a corollary, delays in achieving remission decrease the odds of achieving successful maintenance with an SSI alone. Avoiding such delays, most notably in patients with normal strength, may reset the natural history of anti-HMGCR myopathy from a refractory entity to a treatable disease.
Collapse
Affiliation(s)
- Alain Meyer
- Faculté de médecine, Université de Strasbourg, Service de rhumatologie et Centre de références des maladies autoimmunes rares, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Yves Troyanov
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Hôpital du Sacré-Coeur, Montreal, Québec, Canada
| | - Julie Drouin
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre hospitalier affilié universitaire régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Geneviève Oligny-Longpré
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada
| | - Océane Landon-Cardinal
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada.,CHUM Research Center, Montréal, Québec, Canada
| | - Sabrina Hoa
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada.,CHUM Research Center, Montréal, Québec, Canada
| | - Baptiste Hervier
- Service de médecine interne et immunologie clinique, Hôpital Pitié-Salpêtrière, Assistance publique Hôpitaux de Paris, Paris, France
| | - Josiane Bourré-Tessier
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada.,CHUM Research Center, Montréal, Québec, Canada
| | - Anne-Marie Mansour
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Internal Medicine, Hôpital du Sacré-Coeur, Montréal, Québec, Canada
| | - Sara Hussein
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada
| | - Vincent Morin
- Faculty of Pharmacy, Laval University, Québec City, Québec, Canada
| | - Eric Rich
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada.,CHUM Research Center, Montréal, Québec, Canada
| | - Jean-Richard Goulet
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada
| | - Sandra Chartrand
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Canada.,Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Jessica Nehme
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Internal Medicine, Hôpital du Sacré-Coeur, Montréal, Québec, Canada
| | - Jean-Paul Makhzoum
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Internal Medicine, Hôpital du Sacré-Coeur, Montréal, Québec, Canada
| | - Farah Zarka
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Internal Medicine, Hôpital du Sacré-Coeur, Montréal, Québec, Canada
| | - Edith Villeneuve
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada
| | - Jean-Pierre Raynauld
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada
| | - Marianne Landry
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada.,Division of Internal Medicine, Hôpital du Sacré-Coeur, Montréal, Québec, Canada
| | - Erin K O'Ferrall
- Department of Neurology, McGill University, Montreal, Canada.,Montreal Neurological Institute and Hospital, Montreal, Canada.,Department of Pathology, McGill University, Montreal Neurological Institute and Hospital, Montreal, Québec, Canada
| | - Jose Ferreira
- Department of Pathology and Cell Biology, Faculty of Medicine, University of Montreal, Montreal, Canada.,Department of Pathology, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Benjamin Ellezam
- Department of Pathology and Cell Biology, Faculty of Medicine, University of Montreal, Montreal, Canada.,Department of Pathology, Hôpital Sainte-Justine, Montreal, Canada
| | - Jason Karamchandani
- Montreal Neurological Institute and Hospital, Montreal, Canada.,Department of Pathology, McGill University, Montreal Neurological Institute and Hospital, Montreal, Québec, Canada
| | - Sandrine Larue
- Department of Medicine, Sherbrooke University, Sherbrooke, Québec, Canada.,Division of Neurology, Hôpital Charles-Lemoyne, Longueuil, Canada
| | - Rami Massie
- Department of Neurology, McGill University, Montreal, Canada.,Montreal Neurological Institute and Hospital, Montreal, Canada
| | - Catherine Isabelle
- Department of Medicine, Sherbrooke University, Sherbrooke, Québec, Canada.,Division of Rheumatology, Hôpital Charles-Lemoyne, Longueuil, Québec, Canada
| | - Isabelle Deschênes
- Department of Medicine, Sherbrooke University, Sherbrooke, Québec, Canada.,Hôpital du Haut-Richelieu, Saint-Jean-sur-Richelieu, Québec, Canada
| | - Valérie Leclair
- Department of Medicine, McGill University, Montreal, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Canada
| | - Hélène Couture
- Departement of Medicine, Laval University, Québec City, Canada.,Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada
| | - Ira N Targoff
- Veterans Affairs Medical Center, University of Oklahoma Health Sciences Center, Oklahoma City, USA.,Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Marvin J Fritzler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jean-Luc Senécal
- Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada. .,Division of Rheumatology, Centre Hospitalier de l'Université de Montréal (CHUM), 264, Boulevard René-Lévesque Est, Montréal, Québec, H2X 1P1, Canada. .,CHUM Research Center, Montréal, Québec, Canada.
| |
Collapse
|